DOH 667-032 September 2021
Nursing Assistant Expired Certication Activation
Application Packet
Contents:
1. 667-032 ......Contents List/SSN Information/Mailing Information .....................1 page
2. 667-033 ......Application Instructions Checklist ............................................... 2 pages
3. 667-034 ......Nursing Assistant Expired Certication Activation Application.... 3 pages
4. RCW/WAC Links and Online Websites Links ..................................................1 page
Important Social Security Number Information:
If you have a Social Security Number, the law requires you to disclose it on your
application for a professional or occupational license. 42 U.S.C. § 666(a)(13); RCW
26.23.150. It will be used under the state’s child support enforcement program to locate
individuals for purposes of establishing paternity and establishing, modifying, and
enforcing support obligations. You are not required to have or obtain a Social Security
Number to apply for or obtain a license from the Department of Health. If you do not
have a Social Security Number, you are still eligible to apply for and obtain a credential
if you meet the requirements. Please see the Declaration of No Social Security Number
Form. Please call the Customer Service Center at 360-236-4700 if you have questions.
In order to process your request:
Mail your application with initial
documentation and your check Send other documents not sent
or money order payable to: with initial application to:
Department of Health Nursing Assistant Credentialing
PO Box 1099 PO Box 47877
Olympia, WA 98507-1099 Olympia, WA 98504-7877
Contact us:
360-236-4700
To request this document in another format, call 1-800-525-0127. Deaf or hard of
hearing customers, please call 711 (Washington Relay) or email civil.rights@doh.
wa.gov.
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DOH 667-033 September 2021 Page 1 of 2
You will be notied in writing if further documentation is required.
To ensure that you have submitted the necessary fees and documentation, we encourage
you to use the following checklist:
F Pay Late Renewal Penalty Fee.
F Pay Current Renewal Fee.
F Pay Expired Certication Reissuance Fee.
All fees are non-refundable. You can check the fee page for current fees.
F 1. Demographic Information.
Social Security Number: You must list your social security number on your
application. You are not required to have or obtain a Social Security Number to apply
for or obtain a license from the Department of Health. Please see the Declaration of
No Social Security Number Form. Please call the Customer Service Center at 360-
236-4700 if you do not have one.
National Provider Identier Number (NPI): The National Provider Identier (NPI) is
a standard unique identier for health care professionals available from the Federal
Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric identier. If
you have a NPI number, provide this on your application.
Legal Name: List your full name: rst, middle, and last
Denition of legal name: “Legal name” is the name appearing on your ocial
certicate of birth or, if your name has changed since birth, on an ocial marriage
certicate or an order by a court. The court must have the legal authority to change
your name. We may ask you to prove your legal name. If you use any name other
than your legal name on this form, your application may be denied.
Birth date: Provide the month, day, and year of your birth.
Address: List the address we should use to send any information on your
certication. Be sure to include the city, state, zip code, county and country. This will
be your permanent address with Department of Health until we have been notied of a
change. See WAC 246-12-310.
Phone, Fax, and Cell Numbers: Enter your phone, fax, and cell numbers, if you have
them.
Email: Enter your email address, if you have one.
Other Name(s): Indicate whether you are known or have been known under any
other names. If you have a name change, you must notify the Department of Health in
writing. You must include proof of this change. See
WAC 246-12-300.
Application Instructions Checklist
F 2. Other License, Certication, or Registration. List in date order, most recent to
later, all credentials you have held since last being credentialed in Washington State.
Include your last active credential in Washington State. Attach additional pages, if you
need more space.
F 3. Professional Caregiving Experience. In date order, list all your professional work
experience since your Washington State credential expired. Attach additional pages,
if you need more space.
F 4. Disciplinary Action Attestation. Required by
WAC 246-12-040.
F 5. Continuing Education Attestation. Required by WAC 246-12-040.
F 6. Applicant’s Attestation. Required to be both signed and dated in order to process
the application.
DOH 667-033 September 2021 Page 2 of 2
DOH 667-034 September 2021 Page 1 of 3
Revenue IF 0299030000 --56-
Date
Stamp
Here
Name First Middle Last
Note: The mailing and email addresses you provide will be your addresses of record. It is your
responsibility to maintain current contact information on le with the department.
Country
Will documents be received in another name? F Yes F No If yes, list name(s):
Address
City State Zip Code County
Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #)
Email address
Have you ever been known under any other name(s)? F Yes F No If yes, list name(s):
Country
Mailing address if dierent from above address of record
City State Zip Code County
Birth date (mm/dd/yyyy)
1. Demographic Information
Please print clearly. Follow the instructions provided. It is the responsibility of the applicant to submit or request all
required supporting documents be submitted. Failure to do so may result in a delay in processing your application.
Nursing Assistant Expired
Certied Activation Application
F Male F Female
F Prefer Not to Answer
F X
Social Security Number (SSN)
(If you do not have a SSN, see instructions)
National Provider Identier Number (NPI)
(Enter 10 digit number)
Nursing Assistant Certied Credentialing
P.O. Box 1099
Olympia, WA 98507-1099
DOH 667-034 September 2021 Page 2 of 3
2. Other License, Certication, or Registration (Include Previous Credentials in Washington State)
State/Jurisdiction
Profession
Credential
Type
Year IssuedNumber
Yes
Method of
Credentialing
Currently in Force
No
3. Professional Experience
Type of experience of practice and location Start (mm/yyyy)
End (mm/yyyy)
4. Disciplinary Action Attestation
I certify no action has been taken by any state or federal jurisdiction or hospital, which would prevent
or restrict my right to practice my profession.
I further certify I have not voluntarily given up any credential or privilege or have not been restricted in
the practice of my profession in lieu of or to avoid formal action.
Applicant’s Initials Date
6. Applicant’s Attestation
I, ________________________________ , declare under penalty of perjury under the laws of the state of
Washington that the following is true and correct:
• I am the person described and identied in this application.
• I have read RCW 18.130.170
and RCW 18.130.180 of the Uniform Disciplinary Act.
• I have answered all questions truthfully and completely.
• The documentation provided in support of my application is accurate to the best of my
knowledge.
• I have read all laws and rules related to my profession.
I understand the Department of Health may require more information before deciding on my application. The
department may independently check conviction records with state or federal databases.
I authorize the release of any les or records the department requires to process this application. This
includes information from all hospitals, educational or other organizations, my references, and past and present
employers and business and professional associates. It also includes information from federal, state, local or
foreign government agencies.
I understand that I must inform the department of any past, current or future criminal charges or
convictions. I will also inform the department of any physical or mental conditions that jeopardize my ability
to provide quality health care. If requested, I will authorize my health providers to release to the department
information on my health, including mental health and any substance abuse treatment.
Dated ______________________________By: ______________________________________________
(Original Signature of Applicant)
(Print applicant name clearly)
DOH 667-034 September 2021 Page 3 of 3
(mm/dd/yyyy)
I certify that I have met all continuing education and continuing competency requirements for the past two years.
I am enclosing documentation on all classes attended/claimed.
5. Continuing Education/Continuing Competency Attestation (if applicable)
Applicant’s Initials Date
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RCW/WAC and Online Website Links
RCW/WAC Links
Uniform Disciplinary Act, RCW 18.130
Administrative Procedure Act, RCW 34.05
Administrative Procedures and Requirements, WAC 246-12
Nursing Assistance Law, RCW 18.88
Nursing Assistance Rules, WAC 246-841
Online
Nursing Assistant Program, Web page
RCW/WAC and Online Website Links September 2021
